Three Tensions In Medical Innovation To Watch For In 2013

As we anticipate a new year characterized by unprecedented interest in healthcare innovation, pay particular attention to the following three emerging tensions in the space.

Tension 1: Preventive Health vs Excessive Medicalization

A core tenet of medicine is that it’s better to prevent a disease (or at least catch it early) than to treat it after it has firmly taken hold. This is the rationale for both our interest in screening exams (such as mammography) as well as the focus on risk factor reduction (e.g. treating high blood pressure and high cholesterol to prevent heart attacks).

The problem, however, is that intervention itself carries a risk, which is sometimes well-characterized (e.g. in the case of a low-dose aspirin for some patients with a history of heart disease) but more often incompletely understood.

As both Eric Topol and Nassim Taleb have argued, there’s a powerful tendency to underestimate the risk associated with interventions. Topol, for example, has highlighted the potential risk of using statins to treat patients who have never had heart disease (i.e. primary prevention), a danger he worries may exceed the “relatively small benefit that can be derived.” (Other cardiologists disagree – see this piece by colleague Matt Herper).

In his new book Antifragile, Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.”

Both Topol and Taleb are right that we tend to underestimate iatrogenicity in general, and often fail to factor in the small but real possibility of potential harm.

At the same time, I also worry about external experts deciding categorically what sort of risk is or isn’t “worth it” for an individual patient – a particular problem in oncology, where it now seems fashionable to declare the possibility of a few more months of life a marginal or insignificant benefit.

Even less dramatically, a treatment benefit that some might view as trivial (for hemorrhoids, say) might be life-altering for others. For these sufferers, a theoretical risk that some (like Taleb) find prohibitive might be worth the likelihood of symptom relief. Ideally, this decision would ultimately belong to patients, not experts asserting to act on patients’ behalf.

Tension 2: Relentless Standardization of Medicine

Every day, I feel like I’m witnessing two parallel, completely different narratives about the current and future state of medicine. One view – which might be termed the “Cheesecake Factory” perspective – is that medicine is currently practiced in an absurdly capricious fashion; medical care is wildly and unjustifiably variable. Instead, medicine should be standardized like other business processes, so each patient will receive the best known care for their particular condition, rather than be subject to the whims and caprices of the treating physician.

The other story I hear is that in the evolving standardization of medicine – as physician visits become more focused on EMR data entry and adherence to mandated algorithms — something vital is being lost. From this point of view, the advice of the efficiency experts and technologists is seen as dangerously reductive, representing a naïve caricature of medicine, where patients report symptoms, receive a diagnosis, and are assigned a treatment. The reality, say many physicians (see here, for example), is so much messier – symptoms are often vague, reasons for the visit are often complex, there is no clearly-defined “best practice,” and the problem to be solved is often so much more nuanced that “what’s wrong with my car.”

Cheesecake Factory advocates stress they aren’t seeking to remove the nuance from medicine, and instead wish only to standardize what is already known, collect data and determine best practices so that physicians can focus on the interpersonal interaction while knowing they are treating patients in context of all available data. It’s a compelling vision.

Yet it’s hard not to worry that if medicine goes in the direction of the Cheesecake Factory, where care is administered on the cheap by customer-service technologists plugging data into an algorithm, then an ancient and noble profession will face extinction because of an inability (some might say a haughty unwillingness) to adequately contemplate and communicate its essential value proposition.

I am overwhelmed by a feeling of tragic sadness as I see the pervasive sense of dissatisfaction that has settled over medicine, leaving so many honorable, brilliant, well-intentioned doctors in a near-state of shock, asking whether this could possibly be the profession they had dreamt of all their lives, and worked so hard to enter.

On optimistic days, I am hopeful that the process improvements and advances in digital health will inspire, not dishearten, inquisitive physicians, who perhaps will appreciate the opportunity to more fully leverage information and deliver a higher level of care.

I’m also certain that if medicine does continue to become as excessively standardized and depersonalized as many fear, this will create important disruptive opportunities for entrepreneurial physicians with a different – call it old-fashioned – vision of the value of a more substantial doctor-patient relationship.

Tension 3: Industrialization of Drug Discovery

The most significant problem facing the biopharma industry today is that large biopharmas depend upon products they have little idea how to reliably discover. It’s a strange concept, when you think about it – and a huge challenge for the industry, since most of what large companies do very well – industrialize processes, produce products at scale – just don’t map all that well to the skills and capabilities required for discovering new drugs.

It’s not a new problem, of course, but one big pharma R&D execs continue to struggle with – and paeans to open innovation aside, it’s not clear they’ve landed upon any sort of viable solution.

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Many important and interesting points here. This article highlights the challenges of healthcare. But more importantly begins to attack the fundamental premise of what is healthcare and who is the principle customer of healthcare, or why is healthcare practiced. It is clear that today it is a very big business that pays little attention to the end user/customer, the patient. The first point relating to prevention challenges the perception that it is the doctor deciding on the health of the patient.there is no doubt that a portion of the risks can be calculated by traditional medical methods but we, the patients, are learning that the doctors don’t know everything. Medicine is a continually evolving practice and the patient must be made aware so that they can make their own decisions in relation to their own health. The doctor needs to provide the present state of understanding to the patient with the reality that the present state will be outdated sooner or later, and then allow the patient to influence the decision for intervention. Disease is a completely different state then health….pathophysiology vs. physiology! This relates directly and supports the second point in this article where there needs to be a joint patient-doctor partnership in managing health and healthcare of the patient. In terms of drug development, there does need to be an overhaul of the process. This does include some serious engineering of the process but the fundamental approaches are broken. It is very difficult to fix a broken system! Time to re-evaluate the strategy and tactics (process) and I don’t believe big Pharma is capable of this as they created the mess! Great article!

Brilliant synthesis of some very complex issues. Ever since The Cheesecake Factory’s business process was floated as a model for standardizing medicine – which I initially thought was an Onion post, and still suspect is a giant joke with an unfortunate punchline – I’ve worried that the last vestiges of humanity in medicine were on the verge of being surgically removed.

Medicine is as much an art as a science, with individual practitioners and patients working together to figure out how a unique organism – a human – can be either kept healthy, or regain health. I know from my own cancer experience that every medical journey is different, even if much of the process and outcome can be predicted by scientific evidence. How can that be rendered in an algorithm?

And don’t get me started on Big Pharma. Most of their efforts seem focused on getting patients to rush the doors of their doctors to “ask about” the latest miracle drug. Asking “are we helping?” would be much more productive, but given FDA rules and pharma’s own relentless pursuit of ROI above all else, there’s little hope of that happening soon.

Appreciate your comments; I confess to having a somewhat different take on big pharma (and note of course I work in the industry). I believe drug developers face a task far more difficult than most appreciate, and are fundamentally trying to do something that could be very meaningful – come up with new medicines for terrible diseaes. It’s obviously a large and complex discussion, but this may be a useful place to start: http://www.forbes.com/sites/davidshaywitz/2012/03/29/youre-welcome-the-vital-role-companies-play-in-pressure-testing-academic-medical-research/ .

Great Article. In regards to the early intervention, (Preventive Health) one must consider another motivator, that being profit. I am a big fan of preventative health treatments, but I think the point that some do more harm than good has to be monitored as much by the patient as any other professional body.